B cell lineage acute lymphoblastic leukemia (ALL) represents by far the most frequent type of malignancy in children and teenagers. Despite significant advances in ALL treatment, many patients still die because of drug- resistance or leukemia relapse. Since recent work implicated leukemia stem cells in both drug-resistance and relapse of the disease, current therapy approaches focus on leukemia stem cell eradication. In contrast to B cell lineage ALL, leukemia stem cells in myeloid lineage leukemia have been extensively characterized. Acute and chronic myeloid leukemias develop hierarchically from a phenotypically distinct stem cell population. However, recent work suggests that no such hierarchy exists in B cell lineage ALL, which precludes an unequivocal phenotypic definition of leukemia stem cells in ALL. Therefore, we propose to functionally characterize leukemia stem cells in B cell lineage ALL based on an operational definition, i.e. the ability to maintain stem cell self-renewal and overcome oncogene-induced senescence. Specifically, we will test the hypothesis that the BCL6 transcriptional repressor represents one of the critical factors in B cell lineage ALL to maintain a pool of functional leukemia stem cells. The BCL6 proto-oncogene is frequently translocated in diffuse large B cell lymphoma (DLBCL) and maintains self-renewal capacity of DLBCL cells by transcriptional repression of p53 in the lymphoma cells. However, an oncogenic function of BCL6 has not been described in other cell types so far. In preliminary studies for this proposal, we have discovered aberrant expression of BCL6 as a central component of a fundamentally novel pathway of leukemia stem cell maintenance: BCL6 prevents leukemia stem cell depletion through negative regulation of the Arf/p53/p21 pathway in B cell lineage ALL. Compared to leukemias from BCL6-/- mice, BCL6 is required for the reactivation of an early embryonic gene expression program, development of drug-resistance, leukemia cell colony formation and leukemia-initiation in serially transplanted NOD/SCID mice in B cell lineage but not myeloid lineage leukemia. A novel retro-inverso BCL6 peptide inhibitor (RI-BPI) strongly synergized with tyrosine kinase inhibitors in the treatment of B cell lineage ALL cells in vitro and in vivo. This proposal will test the hypothesis that BCL6-dependent self-renewal represents a critical requirement for stem cell maintenance in B cell lineage ALL. Based on the discovery of BCL6 as a key component of a fundamentally novel pathway of stem cell self-renewal in various subtypes of ALL, we propose three Aims to develop these findings towards application in patient care: (1) To test the hypothesis that aberrant expression of BCL6 in leukemia cells prevents Arf/p53-mediated senescence and promotes stem cell quiescence, (2) To identify transcriptional targets of BCL6 in primary human leukemia cells and their contribution to self-renewal signaling and (3) To validate BCL6-BPI as a therapy adjuvant for targeted eradication of leukemia stem cells. PUBLIC HEALTH RELEVANCE: Despite significant advances in the treatment of leukemia over the past four decades, the rate of long-term survival has reached a plateau and still large numbers of leukemia patients die, mostly because of relapse and drug-resistance, which was recently attributed to the persistence of leukemia stem cells. If a therapy succeeds in eradicating leukemia stem cells, de novo initiation of the disease (relapse) is no longer possible. Therapeutic progress in recent clinical trials has likely been stalled, partly because current cytotoxic therapy approaches target proliferating bulk leukemia cells rather than quiescent leukemia stem cells. We now discovered that BCL6, a factor known to play a central role in B cell lymphomas, also plays a key role in the maintenance of leukemia stem cells. Since leukemia stem cells represent the origin of relapse and drug-resistance in leukemia in many cases, the identification of BCL6 as a target for leukemia stem cell eradication holds great promise. BCL6 is a master regulatory factor that controls the production of many different important genes. BCL6 was not previously known to be involved in leukemias. In preliminary studies for this proposal, we have discovered aberrant expression of BCL6 as a central component of a fundamentally novel pathway of leukemia stem cell self-renewal and drug-resistance in a wide array of human leukemias, some of which are still difficult to treat. In these leukemias, drug-treatment results in aberrant production of BCL6 by the leukemia cells, which appears to allow leukemia stem cell to self-renew and become resistance against drug-treatment. Recently a drug has been developed that can attach to BCL6 and block its cancer-causing activities. We found that this BCL6 inhibitor, which is called RI-BPI, has strong synergistic activity when combined with conventional drug- treatment, which opens up a powerful new therapeutic strategy for leukemia stem cell eradication through targeted inhibition of BCL6. Based on the discovery of BCL6 as a key component of a novel pathway of drug-resistance and stem cell self-renewal in a wide array of leukemias, we propose three Aims to develop these findings towards application in patient care: (1) To test the hypothesis that aberrant expression of BCL6 in human leukemia cells promotes leukemia stem cell survival, (2) To determine the frequency and phenotype of BCL6-dependent leukemia stem cells in human B cell ALL and (3) To validate a the role of the BCL6 inhibitor RI-BPI as a therapy for targeted eradication of leukemia stem cells. Since RI-BPI is currently going through the process of approval for use in clinical trials, we expect to be able to test the power of this approach in clinical trials by the end of the funding period.